- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.13 / $1,782.00 / $9,034.00
| Facility | | $928.13 | $1,782.00 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.26 / $928.13 / $928.13
| Professional | | $695.26 | $928.13 | $928.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $1,351.31 / $1,351.31
| Professional | | $157.59 | $1,351.31 | $1,351.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.00 / $5,749.00 / $12,152.00
| Facility | | $2,896.00 | $5,749.00 | $12,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.03 / $992.18 / $1,513.45
| Professional | | $676.03 | $992.18 | $1,513.45 |